eMRCS Upper Limb and Breast Flashcards
Which of the following forms the floor of the anatomical snuffbox?
Radial artery Cephalic vein Extensor pollicis brevis Scaphoid bone Cutaneous branch of radial nerve
Scaphoid bone
The scaphoid bone forms the floor of the anatomical snuffbox. The cutaneous branch of the radial nerve is much more superficially and proximally located.
A 35 year old man falls and sustains a fracture to the medial third of his clavicle. Which vessel is at greatest risk of injury?
Subclavian artery Subclavian vein External carotid artery Internal carotid artery Vertebral artery
Subclavian vein
The subclavian vein lies behind subclavius and the medial part of the clavicle. It rests on the first rib, below and in front of the third part of the subclavian artery, and then on scalenus anterior which separates it from the second part of the artery (posteriorly).
A 32 year old attends neurology clinic complaining of tingling in his hand. He has radial deviation of his wrist and there is mild clawing of his fingers, with the 4th and 5th digits being relatively spared. What is the most likely lesion?
Ulnar nerve damage at wrist Ulnar nerve damage at elbow Radial nerve damage at elbow Median nerve damage at wrist Median nerve damage at elbow
Ulnar nerve damage at elbow
The ulnar paradox - the higher the lesion, the less the clawing of the fingers seen clinically.
At the elbow the ulnar nerve lesion affects the flexor carpi ulnaris and flexor digitorum profundus.
An 8 year old boy falls onto an outstretched hand and sustains a supracondylar fracture. In addition to a weak radial pulse the child is noted to have loss of pronation of the affected hand. Which nerve is compromised?
Median Radial Ulnar Musculocutaneous Axillary
Median nerve
This is a common injury in children. In this case the angulation and displacement have resulted in median nerve injury.
Which of the following carpal bones is a sesamoid bone in the tendon of flexor carpi ulnaris?
Triquetrum Lunate Pisiform Scaphoid Capitate
Pisiform
This small bone has a single articular facet. It projects from the triquetral bone at the ulnar aspect of the wrist where most regard it as a sesamoid bone lying within the tendon of flexor carpi ulnaris.
Which of the following nerves supplies the majority of the skin on the palmar aspect of the thumb?
Ulnar Median Radial Musculocutaneous None of the above
Median nerve
The median nerve supplies cutaneous sensation to this region.
A patient presents to the clinic following a surgical procedure. She complains that she is unable to shrug her shoulder. What is the most likely underlying nerve injury?
Accessory nerve Cervical plexus Ansa cervicalis Long thoracic nerve Axillary nerve
Accessory nerve
The accessory nerve may be injured in operations in the posterior triangle. Injury will affect trapezius.
A 38 year old man falls onto an outstretched hand. Following the accident he is examined in the emergency department. On palpating his anatomical snuffbox there is tenderness noted in the base. What is the most likely injury in this scenario?
Rupture of tendon of flexor pollicis Scaphoid fracture Distal radius fracture Rupture of flexor carpi ulnaris tendon None of the above
Scaphoid fracture
FOOSH is a common mechanism of injury for a scaphoid fracture. This should be suspected clinically if there is tenderness in the base of the anatomical snuffbox. A tendon rupture would not result in bony tenderness.
A 78 year old man is lifting a heavy object when he feels a pain in his forearm and is unable to continue. He has a swelling over his upper forearm. An MRI scan shows a small cuff of tendon still attached to the radial tuberosity consistent with a recent tear. Which of the following muscles has been injured?
Pronator teres Supinator Anconeus Brachioradialis Biceps brachii
Biceps brachii
Biceps inserts into the radial tuberosity. Distal injuries of this muscle are rare but are reported and are clinically more important than more proximal ruptures.
Through which of the structures listed below does the axillary nerve pass?
Quadrangular space Triangular space Subclavicular space Subpectoral space Intercostal space
Quadrangular space
A 43 year old lady is due to undergo an axillary node clearance as part of treatment for carcinoma of the breast. Which of the following fascial layers will be divided during the surgical approach to the axilla?
Sibsons fascia Pretracheal fascia Waldeyers fascia Clavipectoral fascia None of the above
Clavipectoral fascia
The clavipectoral fascia is situated under the clavicular portion of pectoralis major. It protects both the axillary vessels and nodes.
During an axillary node clearance for breast cancer the clavipectoral fascia is incised and this allows access to the nodal stations. The nodal stations are; level 1 nodes inferior to pectoralis minor, level 2 lie behind it and level 3 above it.
During a Patey Mastectomy, surgeons divide pectoralis minor to gain access to level 3 nodes. The use of sentinel node biopsy (and stronger assistants!) have made this procedure far less common.
A 73 year old lady with long standing atrial fibrillation develops a cold and pulseless white arm. A brachial embolus is suspected and a brachial embolectomy is performed. Which of the following structures is at greatest risk of injury during this procedure?
Radial nerve Cephalic vein Ulnar nerve Median nerve None of the above
Median nerve
The median nerve lies close to the brachial artery (medial to it) in the antecubital fossa. This is the usual site of surgical access to the brachial artery for an embolectomy procedure. The median nerve may be damaged during clumsy application of vascular clamps to the artery.
A 73 year old man undergoes an excision biopsy of a lymph node that is closely applied to sternocleidomastoid. This muscle is mobilized and a nerve that is present is damaged. Which muscle below is most likely to be affected?
Trapezius Rhomboid major Deltoid Supraspinatus Rhomboid minor
Trapezius
The accessory nerve has a number of lymph nodes applied to it near the sternocleidomastoid muscle. It is particularly at risk if SCM is mobilized. If injured, the trapezius muscle and SCM will be paralysed.
Which of the following structures separates the ulnar artery from the median nerve?
Brachioradialis Pronator teres Tendon of biceps brachii Flexor carpi ulnaris Brachialis
Pronator teres (deep head)
The ulnar artery lies deep to pronator teres and this separates it from the median nerve.
Which of the following muscles lies medial to the long thoracic nerve?
Serratus anterior Latissimus dorsi Coracobrachialis Pectoralis minor None of the above
Serratus anterior
A 10 year old boy is admitted to the emergency department following a fall. On examination, there is deformity and swelling of the forearm. The ability to flex the fingers of the affected limb is impaired. However, there is no sensory impairment. Imaging confirms a displaced forearm fracture. Which of the nerves listed below is likely to have been affected?
Ulnar nerve Posterior interosseous nerve Anterior interosseous nerve Axillary nerve Radial nerve
Anterior interosseous nerve
Forearm fractures may be complicated by neurovascular compromise. The anterior interosseous nerve may be affected. It has no sensory supply so the defect is motor alone.
Which of the muscles listed below is attached to the anterior aspect of the fibrous capsule that encases the elbow joint?
Pronator teres Biceps Brachialis Triceps Extensor carpi radialis longus
Brachialis
The brachialis inserts some of its fibres into the fibrous joint of the elbow capsule and when it contracts, it helps to flex the joint.
Which of the following muscles does not adduct the shoulder?
Teres major Pectoralis major Coracobrachialis Latissimus dorsi Supraspinatus
Supraspinatus
Supraspinatus is an abductor of the shoulder.
What is the course of the median nerve relative to the brachial artery in the upper arm?
Medial to anterior to lateral Lateral to posterior to medial Medial to posterior to lateral Medial to anterior to medial Lateral to anterior to medial
Lateral to anterior to medial
The median nerve descends lateral to the brachial artery, it usually passes anterior to the artery to lie on its medial side.
It passes deep to the bicipital aponeurosis and the median cubital vein at the elbow.
It enters the forearm between the two heads of the pronator teres muscle
Which nerve supplies the skin at the medial aspect of the palm?
Ulnar Radial Median Musculocutaneous Anterior interosseous
Ulnar
Originates from C8-T1.
Path: Posteromedial aspect of upper arm to flexor compartment of forearm, then along the ulnar. Passes beneath the flexor carpi ulnaris muscle, then superficially over the flexor retinaculum into the palm of the hand.
A 40 year old lady trips and falls through a glass door and sustains a severe laceration to her left arm. Amongst her injuries it is noticed that she has lost the ability to adduct the fingers of her left hand. Injury to which of the following nerves is most likely to account for her examination findings?
Ulnar Median Radial Musculocutaneous Axillary
Ulnar nerve
The interossei are supplied by the ulnar nerve.
A 23 year old man is injured during a game of rugby. He suffers a fracture of the distal third of his clavicle, it is a compound fracture and there is evidence of arterial haemorrhage. Which of the following vessels is most likely to be encountered first during subsequent surgical exploration?
Posterior circumflex humeral artery Axillary artery Thoracoacromial artery Subscapular artery Lateral thoracic artery
Thoracoacromial artery
The thoracoacromial artery arises from the second part of the axillary artery. It is a short, wide trunk, which pierces the clavipectoral fascia, and ends, deep to pectoralis major by dividing into four branches.
The anterior interosseous nerve is a branch of which of the following?
Ulnar nerve Superficial branch of radial nerve Axillary nerve Deep branch of radial nerve Median nerve
Median nerve
Anterior interosseous nerve supplies the deep muscles on front of the forearm, except the ulnar half of FDP.
Accompanies anterior interosseous artery along anterior of interosseous membrane of forearm, in the interval between FPL and FDP
Supplies whole of FPL and radial half of FDP
Ends in the pronator quadratus and wrist joint
A 56 year old man requires long term parenteral nutrition and the decision is made to insert a PICC line for long term venous access. This is inserted into the basilic vein at the region of the elbow. As the catheter is advanced, into which venous structure is the tip of the catheter most likely to pass from the basilic vein?
Subclavian vein Axillary vein Posterior circumflex humeral vein Cephalic vein Superior vena cava
Axillary vein
The basilic vein drains into the axillary vein and although PICC lines may end up in a variety of fascinating locations, the axillary vein is usually the commonest site following from the basilic.
The posterior circumflex humeral vein is encountered prior to the axillary vein. However, a PICC line is unlikely to enter this structure because of its angle of entry into the basilic vein.
A 42 year old teacher is admitted with a fall. An x-ray confirms a fracture of the surgical neck of the humerus. Which nerve is at risk?
Median Radial Axillary Musculocutaneous Subscapular
Axillary nerve
The axillary nerve winds around the bone at the neck of the humerus. It is also at risk during shoulder dislocation.
Which of the following structures passes through the quadrangular space near the humeral head?
Axillary artery Radial nerve Axillary nerve Median nerve Transvere scapular artery
Axillary nerve
The quadrangular space is bordered by: Lateral - humerus Superior - subscapularis and teres minor Inferior - teres major Medial - long head of triceps
It lies lateral to the triangular space. It transmits the axillary nerve and posterior circumflex humeral artery.
A 28 year old rugby player injures his right humerus and on examination is noted to have a minor sensory deficit overlying the point of deltoid insertion into the humerus. Which of the nerves listed below is most likely to have been affected?
Radial Axillary Musculocutaneous Median Subscapular
Axillary nerve
This patch of skin is supplied by the axillary nerve
Which nerve supplies the interossei of the fourth finger?
Radial Medial Superficial ulnar Deep ulnar Posterior interosseous
Deep ulnar
Deep ulnar nerve supplies: hypothenar muscles, all interossei, 3rd and 4th lumbricals, adductor pollicis, medial head of flexor pollicis brevis
Superficial ulnar supplies sensation to anterior palmar surfaces of medial 1.5 fingers
A 23 year old man is involved in a fight, during the dispute he sustains a laceration to the posterior aspect of his right arm, approximately 2cm proximal to the olecranon process. On assessment in the emergency department he is unable to extend his elbow joint. Which of the following tendons is most likely to have been cut?
Triceps Pronator teres Biceps Brachioradialis Brachialis
Triceps
The triceps muscle extends the elbow joint. The other muscles listed all produce flexion of the elbow joint.
A 35 year tennis player attends clinic reporting tingling down his arm. He says that his ‘funny bone’ was hit very hard by a tennis ball. There is weakness of abduction and adduction of his extended fingers. Which nerve has been affected?
Ulnar Anterior interosseous Posterior interosseous Median Musculocutaneous
Ulnar nerve
Arises from the medial cord of the brachial plexus (C8, T1 and contribution from C7).
The nerve descends between the axillary artery and vein, posterior to the cutaneous nerve of the forearm and then lies anterior to triceps on the medial side of the brachial artery.
In the distal half of the arm it passes through the medial intermuscular septum, and continues between this structure and the medial head of triceps to enter the forearm between the medial epicondyle of the humerus and the olecranon. It may be injured at this site in this scenario.
A 23 year old man falls and injures his hand. There are concerns that he may have a scaphoid fracture as there is tenderness in his anatomical snuffbox on clinical examination. Which of the following forms the medial border of this structure?
Basilic vein Radial artery Extensor pollicis brevis Abductor pollicis longus Extensor pollicis longus
Extensor pollicis longus
Boundaries of the anatomical snuffbox are extensor pollicis longus medially and laterally by the tendons of abductor pollicis longus and extensor pollicis brevis.
A 25 year old man is stabbed in the upper arm. The brachial artery is lacerated at the level of the proximal humerus, and is being repaired. A nerve lying immediately lateral to the brachial artery is also lacerated. Which of the following is the nerve most likely to be?
Ulnar nerve Median nerve Radial nerve Intercostobrachial nerve Axillary nerve
Median nerve
The brachial artery begins at the lower border of teres major and terminates in the cubital fossa by branching into the radial and ulnar arteries.
In the upper arm the median nerve lies closest to it in the lateral position. In the cubital fossa it lies medial to it.
The profunda brachii artery is related to the radial nerve.
Which muscle initiates abduction of the shoulder?
Infraspinatus Latissimus dorsi Supraspinatus Deltoid Teres major
Supraspinatus
The intermediate portion of the deltoid muscle is the chief abductor of the humerus. However, it can only do this after the movement has been initiated by supraspinatus. Damage to the tendon of supraspinatus is a common form of rotator cuff disease.
What is the first branch of the axillary artery?
Subscapular artery Lateral thoracic artery Thoracoacromial artery Superior thoracic artery Anterior circumflex humeral artery
Superior thoracic artery
1st part (proximal to pec minor): superior thoracic 2nd part (posterior to pec minor): thoracoacromial, lateral thoracic 3rd part (distal): subscapular, anterior and posterior circumflex humeral
Which of the following nerves is responsible for innervation of the triceps muscle?
Radial Ulnar Axillary Median None of the above
Radial nerve
The radial nerve innervates all three heads of triceps, with a separate branch to each head.
The following are true of the ulnar nerve except:
Innervates the palmar interossei
Derived from medial cord of brachial plexus
Supplies muscles of thenar eminence
Supplies medial half of flexor digitorum profundus
Passes superficial to flexor retinaculum
Supplies muscles of thenar eminence
The muscles of the thenar eminence are supplied by the median nerve and atrophy of these is a feature of carpal tunnel syndrome.
Which of the structures listed below articulates with the head of the radius superiorly?
Capitulum Trochlea Lateral epicondyle Ulna Medial epicondyle
Capitulum
The head of the radius articulates with the capitulum of the humerus.
The cephalic vein pierces the clavipectoral fascia to terminate in which of the veins listed below?
External jugular Internal jugular Axillary Azygos Brachial
Axillary vein
Path of cephalic vein: dorsal venous arch drains laterally into cephalic vein
Crosses anatomical snuffbox and travels laterally up arm
At antecubital fossa, connected to basilic vein by median cubital vein
Pierces deep fascia of deltopectoral groove to join axillary vein
Which of the structures listed below are most closely related to the axillary nerve within the quadrangular space?
Posterior circumflex humeral arteries Anterior circumflex humeral arteries Axillary artery Radial artery Acromiothoracic artery
Posterior circumflex humeral arteries
The posterior circumflex humeral vessels which are branches of the axillary artery are related to the axillary nerve within the quadrangular space.
Which of the following fingers is not a point of attachment for the palmar interossei?
Middle finger Little finger Ring finger Index finger None of the above
Middle finger
The middle finger has no attachment of the palmar interosseous.
Note that there are 4 palmar interossei. The first is a small slip of muscle which arises from the ulnar side of the base of the first metacarpal and passes between the head of the first dorsal interosseous and the oblique head of adductor pollicis to insert into the ulnar base of the of the proximal phalanx of the thumb.
The second arises from the ulnar side of the body of the second metacarpal and is inserted into` the ulnar side of the extensor hood of the index.
The third and fourth palmar interossei arise from the radial sides of the bodies of the 4th and 5th metacarpals respectively and insert into the radial sides of the extensor hoods of the ring and little fingers.
A 33 year old man sustains an injury to his forearm and wrist. When examined in clinic he is unable to adduct his thumb. What is the most likely underlying nerve lesion?
Radial nerve Superficial branch of ulnar nerve Median nerve Posterior interosseous nerve Deep branch of ulnar nerve
Deep branch of ulnar nerve
Damage to the deep branch of the ulnar nerve may result in an inability to adduct the thumb. This is tested clinically by trying to withdraw a piece of paper from a patients hand grasped between thumb and index finger.`
Which of the following structures is not closely related to the brachial artery?
Ulnar nerve Median nerve Cephalic vein Biceps Median cubital vein
Cephalic vein
The cephalic vein lies superficially and on the contralateral side of the arm to the brachial artery. The relation of the ulnar nerves and others are demonstrated in the image below:
A 24 year female is admitted to A&E with tingling of her hand after a fall. She is found to have a fracture of the medial epicondyle. What is the most likely nerve lesion?
Ulnar Radial Median Axillary Cutaneous
Ulnar nerve
The radial nerve is located near the lateral epicondyle.
Which of the following muscles does not attach to the radius?
Pronator quadratus Biceps Brachioradialis Supinator Brachialis
Brachialis
The brachialis muscle inserts into the ulna. The other muscles are all inserted onto the radius.
Which of the following is a branch of the third part of the axillary artery?
Superior thoracic Lateral thoracic Dorsal scapular Thoracoacromial Posterior circumflex humeral
Posterior circumflex humeral
The other branches include: Subscapular, anterior circumflex humeral
The dorsal scapular artery arises from the third part of the subclavian artery in most cases.
The dorsal scapular artery arises from the third part of the subclavian artery in most cases
Radial Recurrent branch of median Anterior interosseous Ulnar Median
Median nerve
A 23 year old man has a cannula inserted into his cephalic vein. Through which structure does the cephalic vein pass?
Interosseous membrane Triceps Pectoralis major Clavipectoral fascia Tendon of biceps
Clavipectoral fascia
The cephalic vein penetrates the clavipectoral fascia (but not the pectoralis major) prior to terminating in the axillary vein.
The cephalic vein is a favored vessel for AV fistula formation and should be preserved in patients with ESRF.
Which of these muscles is not a component of the rotator cuff?
Subscapularis Teres minor Supraspinatus Infraspinatus Deltoid
Deltoid
Deltoid may abduct the shoulder and is not a rotator cuff muscle.
With respect to the basilic vein, which statement is false?
Its deep anatomical location makes it unsuitable for use as an AV access site in fistula surgery
It originates from dorsal venous network on the hand
Travels up medial aspect of forearm
Halfway between shoulder and the elbow it lies deep to muscle
Joined by brachial vein to form axillary vein
Its deep anatomical location makes it unsuitable for use as an AV access site in fistula surgery
It is used in AV fistula surgery during a procedure known as a basilic vein transposition.
